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Focus of geriatric oncology shifting from age to patient
Oncologists should familiarize themselves with geriatric medicine to meet the needs of an aging population.
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Physicians face a major epidemiologic challenge ahead, given that the major risk factor for cancer is age and the number of elderly individuals in the United States continues to increase, according to the International Society of Geriatric Oncology, an organization that addresses age-related issues in older adults with cancer. According to The Geriatric Oncology Consortium, a national nonprofit organization also dedicated to tackling age-based cancer issues, one in three Americans older than 60 years will be diagnosed with cancer.
Interest in geriatric oncology research is growing, according to Arti Hurria, MD, associate professor of medical oncology and population sciences and director of the Cancer and Aging Research Program at City of Hope, Comprehensive Cancer Center, in Duarte, Calif.
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Photo by P. Cunningham, City of Hope |
“The quality of research that’s coming out has been outstanding; however, more is needed,” Hurria told HemOnc Today.
There is still much to learn about this increasingly important field, such as determining the appropriate methods for screening and treating older patients, identifying new markers of a patient’s “true age” and easing the burden on relatives providing care for the elderly. HemOnc Today asked experts in the field of geriatric oncology to weigh in on these issues.
Physiologic not chronologic age
It is important to assess elderly patients by their physiologic age rather than by their chronologic age, according to Lodovico Balducci, MD, professor of medicine and oncology at the University of South Florida College of Medicine and chief of the division of Geriatric Oncology at Moffitt Cancer Center in Tampa, Fla.
Older people make up the largest segment of the cancer population, and yet optimal treatment for many of them has not been defined, Balducci wrote on The Geriatric Oncology Consortium website.
Patients of the same or similar age may have very different functional ages. Therefore, rather than use a numeric age, which will likely reveal limited information about an older patient, identifying markers such as functional assessment, cognitive or mental status, number of comorbidities and number of prescribed medications may help more accurately predict how a patient will handle treatment therapies.
“The majority of older patients with cancer will benefit from cancer treatments as much as younger patients, whereas some may require alternative treatments due to contraindication. So, assessing physiologic age is essential,” Balducci told HemOnc Today.
Currently, there is no single standard formula or model for stratifying elderly individuals with cancer; however, there are some reasonable guidelines, according to William Dale, MD, PhD, associate professor of medicine and section chief, Geriatrics and Palliative Medicine, at the University of Chicago Medical Center.
“We are starting to see standards being developed in geriatric oncology,” Dale said.
Prediction models
At the 2010 ASCO annual meeting, Hurria and Martine Extermann, MD, PhD, president of the International Society of Geriatric Oncology and senior faculty member at H. Lee Moffitt Cancer Center, presented a prediction model for determining risk factors for chemotherapy toxicity in elderly individuals with cancer.
According to Stuart Lichtman, MD, Attending, Clinical Geriatric Program at Memorial Sloan-Kettering Cancer Center in New York, the study findings of Hurria and Extermann demonstrated that toxicity may be able to be predicted using a very simple clinical tool.
“When I say simple, I mean asking a patient how many falls they’ve had and determining their hearing and kidney function and a few other simple questions,” Lichtman said.
In the study by Hurria and a consortium of researchers from the Cancer and Aging Research Group, 500 patients aged at least 65 years from seven institutions were followed longitudinally.
Before initiation of chemotherapy, the researchers assessed factors besides age that may predict vulnerability to toxicity, including functional status, nutritional status, comorbidity, cognition, psychological state and social support.
Risk factors for grade 3 to grade 5 toxicity included age 73 years and older, cancer type, standard dose, poly-chemotherapy, at least one fall in the last 6 months, need for assistance with instrumental activities and decreased social activity.
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The researchers then developed a predictive model showing the percentage of incidence of grade 3 to grade 5 toxicity, based on the number of risk factors: one factor, 23%; two, 36%; three, 50%; four, 60%; five, 83%; six, 90%; and seven, 100%.
Extermann and colleagues created another predictive model, the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score, to analyze the effectiveness of using a clinical geriatric assessment tool to predict toxicity. They evaluated data from 518 patients aged at least 70 years from seven different institutions in Florida.
According to the researchers, the CRASH score provided a validated, clinically applicable means of predicting differences in severe chemotherapy toxicity risk in older patients with cancer. They added, it is “a useful tool to individualize treatment choices on an objective basis.”
Biomarkers on the horizon
In addition to studies of predictive models that determine which treatments may or may not benefit elderly patients with cancer, research is focusing on biological or molecular causes of aging and how they relate to cancer, according to Arash Naeim, MD, associate professor in residence, hematology and oncology, at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles.
One potential biomarker may be inflammatory markers and their overlap with other molecular markers that are released when a patient develops cancer.
“There is a fair amount of research on whether inflammatory markers and these other markers reflect each other or whether they are prognostic of an individual becoming frail,” Naeim told HemOnc Today.
Another potential biomarker that may help paint a more accurate picture of physiologic age is determining the length of an individual’s telomeres.
Balducci cited data from a longitudinal study published in the Journal of the American Medical Association in July, demonstrating that there was a statistically significant inverse relationship between telomere length and cancer incidence and mortality.
The HR for incident cancer was 3.11 (95% CI, 1.65-5.84) in the shortest telomere length group compared with the longest telomere length group. Incidence rates were 5.1 (95% CI, 2.9-8.7) per 1,000 person-years in the longest group vs. 22.5 (95% CI, 16.9-29.9) per 1,000 person-years in the shortest group. Finally, short telomere length was associated with cancer mortality (HR=2.13; 95% CI, 1.58-2.86) and individual cancer subtypes with a high fatality rate, according to the researchers.
Another molecular marker that may help predict toxicities among the older population with cancer is the p16INK4a gene, a tumor suppressor gene that is part of the cell cycle. Hyman B. Muss, MD, professor of medicine at Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, pointed to studies by Sharpless and colleagues showing expression of the protein in the p16INK4a gene increases by about 10-fold between the ages of 20 and 80 years.
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In a study published in Aging Cell in August, 2009, by Liu, Sharpless and colleagues, findings demonstrated that p16INK4a expression was associated with plasma interleukin-6 concentration, a marker of human frailty. Their data suggested that expression of p16INK4a in peripheral blood T-lymphocytes is an easily measured marker of molecular age.
Two people of the same age could have different levels of expression with the higher levels possibly indicating “older” cells, according to Muss.
“The person with older cells may get more toxicity from chemotherapy, such as myelosuppression, more mucositis, and so forth; hence, markers such as this may be complementary to standard clinical tests in that they may someday aid in predicting more toxicity,” Muss said.
Finding more effective methods of stratifying elderly patients with cancer and predicting potential treatment toxicity are a few of the issues at the forefront of geriatric oncology. A sometimes overlooked issue of geriatric cancer care is that of patient and caregiver emotional and economic support.
Caregiver burden
Most of those caring for elderly patients with cancer are family members who are providing that care out of family obligation, which can be challenging, Hurria said.
“These ‘informal caregivers’ are typically not paid, and there is great personal cost,” she said. “There is an emotional as well as an economic component, which can be difficult on the caregiver as well as the elderly individual with cancer.”
According to Caregiving in the U.S., from the Family Caregiver Alliance, National Center on Caregiving, family caregivers save the health care system an estimated $306 billion a year by not using paid home care staff and instead providing care themselves. Also, according to this report, it is estimated that there are 44.4 million American caregivers, with 79% of them providing care to someone older than 50 years.
Physicians who treat and manage elderly patients with cancer should consider the type of support they receive at home. Many elderly people do not have friends or relatives who are able to care for them if they become ill, according to Muss. Additionally, although there are services and resources available through the Internet, many older people do not use computers.
Many major cancer centers and hospitals have good support programs, but rural areas and smaller hospitals do not typically have the staff and money to provide such programs, Muss said.
“Getting support at home and maintaining independent living is a major issue for many elderly patients with cancer,” Muss said. “Although you may treat a disease, shrink a tumor or prolong survival, if a patient loses function, it is a serious issue.”
According to Balducci, an elderly patient who is ill with no one at home caring for him or her is likely at risk.
“I won’t say I would deny treatment to an older patient who lives alone at home, but certainly I would be hard-pressed to treat certain patients because of the concern that they could experience complications for which they may not be able to find immediate medical access,” Balducci said.
Medicare coverage
Once a physician has determined an elderly patient is capable of dealing with an appropriate treatment and has appropriate support, the issue of payment arises. Medicare covers all patients 65 years and older. However, with the arrival of the federal Affordable Care Act come concerns, including whether or not there will be coverage for new, expensive drugs and therapies, and how patients will pay for indirect medical costs, such as transportation to and from a clinic or hospital.
“We are still a little uncertain about how this will play out, but as more and more complicated and extensive therapies become available that may extend people’s lives for a short time for a very high cost, everybody, including Medicare, is less willing to pay for them,” Dale said. “Once they are approved, Medicare theoretically covers them, but there are still going to be a lot of holes in the system.”
According to Muss, Medicare does a good job covering most reasonable therapies, and aspects of the new health care bill may help fill the doughnut hole, the portion of prescription drugs not covered by Medicare, and may even help acquire oral agents; however, “there are additional costs other than those for treatments.”
“Medicare belongs to an era where most medicine was inpatient, whereas many new therapies are outpatient,” Balducci said.
Indirect costs such as transportation to and from the hospital and social support for the patient are often overlooked.
“I recently had to dismiss an 85-year-old patient who has been a patient of mine for many years because she was unable to keep her last four appointments, and there was no way I could take care of her without seeing her,” Balducci said.
Future of geriatric oncology
With the seemingly unending factors to consider when treating and managing an elderly patient with cancer, many in the field would like to see movement toward cooperation and partnership among all subspecialties in the medical field, as they will all be treating a growing population of aging adults.
“When I give lectures, I tell oncologists they are somewhat all geriatric oncologists, they just don’t know it or haven’t admitted it yet,” Lichtman said.
Although oncologists are busy, there are simple things that can be incorporated into a standard assessment, Lichtman told HemOnc Today, and it is crucial to add geriatric elements for certain elderly patients, especially with the growing aging population.
“Geriatric-related issues are going to be big in oncology, going forward, especially with the aging baby boomers, who will demand a certain level of care we may not have provided in the past,” Dale said.
According to Naeim, managing older patients with cancer will become more mainstream, pointing to the future of geriatric oncology.
“When you are dealing with a concept or situation that you don’t feel completely comfortable with, there is a certain amount of apprehension,” Naeim said. “But, it’s a barrier that can be overcome in a variety of ways.”
At Lineberger Comprehensive Cancer Center, for example, one goal is to educate oncology doctors about geriatrics, according to Muss.
“There is an opportunity to obtain a combined fellowship in medical oncology and geriatrics, in which we’re focusing on training younger people who can move this field even farther forward by uncovering new issues we may not even be aware of related to management and access of care,” he said.
Hurria said education, communication and dissemination of useful information is important in geriatric oncology.
“There is a consortium of researchers across the United States, including the national cooperative groups and the Cancer and Aging Research Group, that are welcoming and want to do this kind of research in partnership with others, because it’s an area of increasing importance,” Hurria said. – by Christen Cona, MA
Do elderly patients with cancer need assessment from a geriatrician or
can their oncologist assess them?
Bridge the gap with partnership between oncologist and geriatric specialist.
It is unfortunate that the number of geriatricians is very small, so it is virtually impossible to have a geriatrician assess everybody who is treated for cancer. In geriatrics, we have focused on trying to teach geriatrics to other groups and other specialties, so that they provide good care to older people. I don’t see why that can’t happen in oncology as well.
Geriatric assessment is one way to bring geriatric thinking into oncology. Oncologists could certainly do geriatric assessment, but they are trained to focus on other certain things. However, focusing on geriatric-type aspects, like functional status and cognitive ability, would be helpful.
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One way to bridge the gap would be to contact a patient’s primary care doctor or geriatrician to get feedback on an elderly patient with cancer. Many times, geriatric syndromes are missed. For example, many physicians don’t tend to ask if a patient has had a fall or don’t inquire about their nutritional status or cognitive ability. Yet, these factors affect not only whether people survive their toxicities, but also play a part in complications they may get from chemotherapy and surgery.
Does every single person older than 70 years need geriatric assessment? No, because there are older people running marathons and such, and it would be inappropriate to ask this type of person if he or she can grocery shop. But there is a group, especially those aged 80 years and older, for example, in whom you should be ensuring functionality or at least asking about it.
In general, geriatricians tend to see sicker people, while oncologists tend to see healthier older people. There is still a group of people who are sent to oncologists who may have cognitive impairment and functional problems; being aware of this would help oncologists determine the best treatment for that patient. Geriatricizing their assessments a bit will help oncologists as they continue to see increasing numbers of older people.
Louise Walter, MD, is associate professor in the department of medicine, division of geriatrics, University of California, San Francisco.
Geriatric assessment is helpful for vulnerable patients, less so for those in good health.
Older patients are a heterogeneous group. The spectrum of impairment ranges from those who are independent to those who are at moderate risk for health deterioration (ie, vulnerable) and to those at a high risk for functional decline or mortality (ie, frail). Evaluation of comorbidity, disability and geriatric syndromes are essential to identify older adults at risk for adverse outcomes.
A multidimensional comprehensive geriatric assessment (CGA) includes a compilation of reliable and valid tools to assess geriatric domains such as comorbidity, functional status, physical performance, cognitive status, psychological status, nutritional status, medication review and social support. Impairments in these geriatric domains have been shown to negatively impact health outcomes in the elderly.
Although a plethora of tools are available, cut-offs for impairment for the more widely utilized individual assessment tools are prospectively associated with increased risk for subsequent disability or mortality in the community-dwelling elderly population.
In general, when coupled with targeted interventions, the benefits of geriatric assessment in older patients may include prolongation of life, prevention of hospitalizations and admissions to long-term care facilities, prevention of geriatric syndromes, recognition of cognitive deficits and improvement of health status. Little is still known about how underlying impairment affects clinical decision-making, patterns of care or outcomes in vulnerable elders with cancer.
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According to the National Cancer Comprehensive Network guidelines, CGA should be a key part of the treatment approach for vulnerable older cancer patients. However, fit older patients (ie, those without significant comorbidity, disability or geriatric syndromes) may not require a full geriatric assessment. It has been well established that these patients do just as well with standard cancer treatment as younger patients. In those with other health status problems or those elders in the “oldest-old” age category (aged 85 or older), CGA can detect unsuspected conditions that may affect cancer treatment.
In oncology, CGA could potentially help with decision-making, be followed to detect changes in geriatric outcomes and identify target areas that would benefit from multidisciplinary geriatric interventions. Despite recent studies demonstrating the feasibility of CGA in oncology, its adoption as standard of care has been slow due to lack of resources and difficulties with interpretation of results or implementation of targeted interventions in specialty oncology clinic settings.
More studies are needed to find out the best ways to integrate geriatric assessment into routine clinical practice and more information is required on the prognostic value of geriatric assessment for oncology patients.
Supriya G. Mohile, MD, is assistant professor of medicine, hematology/oncology, University of Rochester Medical Center, New York.
For more information:
- Extermann M. #9000. Presented at: the 2010 ASCO Annual Meeting; June 4-8; Chicago.
- Hurria A. #9001. Presented at: the 2010 ASCO Annual Meeting; June 4-8; Chicago.
- Liu Y. Aging Cell. 2009;8:439-448.
- National Alliance for Caregiving and AARP. Caregiving in the U.S. Available at: www.caregiving.org/data/04finalreport.pdf. Accessed Oct. 21, 2010.
- Willeit P. JAMA. 2010;304:69-75.